Organization
MALLARD RIDGE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. TRACY HENNESSEE (EXECUTIVE DIRECTOR)
(336) 775-2205
Entity
Organization
Contact information
Practice address
851 OLD WINSTON RD, KERNERSVILLE, NC 27284-8780
(336) 993-7555
Mailing address
851 OLD WINSTON RD, KERNERSVILLE, NC 27284-8780
(336) 775-2205
Taxonomy
Speciality
Code
Description
License number
State
310400000X
Assisted Living Facility
Primary
HAL 029 007
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7805429
—
NC
Enumeration date
03/09/2007
Last updated
08/22/2020
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